Remimazolam versus midazolam for moderate sedation in gastrointestinal endoscopy: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND AIMS: Sedation is commonly used during GI endoscopy to improve patient comfort and procedural tolerance. Midazolam is a widely used agent but may be associated with adverse effects and delayed recovery. Remimazolam, an ultrashort-acting benzodiazepine, has emerged as a potential alternative with rapid onset and recovery. The aim of this review is to compare remimazolam with midazolam for sedation in patients undergoing GI endoscopy.

METHODS

A systematic search was conducted across PubMed, Cochrane CENTRAL Library, Google Scholar, and ClinicalTrials.gov from inception till March 2026. Only randomized controlled trials (RCTs) comparing remimazolam with midazolam for sedation in GI endoscopy and reporting any outcome of interest were considered eligible. Statistical analysis was performed using RStudio (R Foundation for Statistical Computing).

RESULTS

A total of 9 RCTs involving 1251 patients were included. Meta-analysis showed no significant difference in sedation success (risk ratio, 1.49; P = .08) between remimazolam and midazolam in patients undergoing GI endoscopy. However, compared with midazolam, remimazolam significantly reduced induction time (mean difference [MD], -4.39 minutes; P = .04), time to full alertness (MD, -4.65 minutes; P = .012), recovery time (MD, -15.66 minutes; P ≤ .001), and discharge time (MD, -7.62 minutes; P = .04), and was associated with significantly higher patient satisfaction (standardized MD, 0.34; P < .01). In addition, remimazolam significantly reduced the risk of hypotension (odds ratio [OR], 0.47; P < .001) and bradycardia (OR, 0.59; P = .037), while other adverse events were comparable between groups.

CONCLUSIONS

Remimazolam demonstrated sedation success comparable to midazolam in patients undergoing GI endoscopy. However, it was associated with faster induction and recovery times, higher patient satisfaction, and a lower risk of hypotension and bradycardia. These findings suggest that remimazolam may represent a safer and more efficient alternative to midazolam for procedural sedation during GI endoscopy. Nevertheless, substantial heterogeneity observed across several outcomes warrants cautious interpretation of these findings.